In 1972, Congress amended the Social Security Act to make chiropractors eligible for reimbursement under Medicare Part B. Since then, Medicare expenditures on chiropractic services have mushroomed from just $19 million in 1975 to nearly $440 million in 2013. Medicare reimburses over 17 million chiropractic treatments each year.
Unfortunately, this expansion has been tainted by an equally significant growth in improper payments to chiropractors. Like most services billed to Medicare under the Social Security Act, chiropractic treatments must be medically necessary and supported by appropriate documentation. But in recent years, chiropractic care has come under increased scrutiny as practices have failed to meet these key standards for reimbursement. Indeed, a 2016 report by the Department of Health and Human Services’ Office of Inspector General (HHS-OIG) found more than 80% of all Medicare payments for chiropractic services in 2013 went toward medically unnecessary procedures. As a result, the government spent nearly $359 million on unnecessary care.
Improper billing for chiropractic services comes in several forms, including:
Medically Unnecessary Treatments: The Centers for Medicare and Medicaid Services require proof of spinal subluxation by an X-ray or physical examination for any treatment billed to Medicare. Typically, the X-ray must have occurred no more than 12 months before, or three months after, the chiropractor begins treatment. Without such proof of injury, chiropractic treatments are considered medically unnecessary.
Billing for Nonexistent Services: Chiropractors have billed Medicare for services not provided to patients. Fraudsters typically falsify patient records and signatures to make it appear as though patients received the treatments at issue. In one recent example, a chiropractor was criminally indicted for allegedly billing Medicare and private insurers for over $10 million in never-provided services.
Billing for “Maintenance Therapy”: Medicare only covers a chiropractor’s “active/corrective treatment” of spinal subluxation, meaning services rendered must “provide reasonable expectation of recovery or improvement of function.” Medicare will not reimburse for “maintenance therapy,” where no improvement in the patient’s condition can reasonably be expected.
Inadequate Documentation: Chiropractors must record and maintain specific documentation at the outset of any course of treatment and at each subsequent service. Among other requirements, these records must specify the precise level of subluxation and the patient’s treatment plan. Each claim for reimbursement must include the date of the patient’s initial treatment or the date of exacerbation, which affirms the chiropractor has maintained all required documentation on file.
The False Claims Act and other federal and state laws are essential in helping the government enforce these requirements and eliminate fraud in Medicare and other public healthcare programs. The government relies on chiropractors and employees of chiropractic offices with firsthand knowledge of fraud and abuse to bring such scams to light.